What is the recommended treatment for a urinary tract infection (UTI)?

Treatment of Urinary Tract Infections (UTIs)

For uncomplicated cystitis in women, first-line antimicrobial options include nitrofurantoin (100 mg twice daily for 5 days), fosfomycin trometamol (3 g single dose), or pivmecillinam (400 mg three times daily for 3-5 days). 1

Diagnosis and Initial Assessment

• Diagnosis of uncomplicated cystitis can be made based on symptoms such as dysuria, frequency, urgency, and absence of vaginal discharge
• Urine culture is recommended in specific situations:
  • Suspected acute pyelonephritis
  • Symptoms that don't resolve or recur within 4 weeks after treatment
  • Women with atypical symptoms
  • Pregnant women 1

Treatment Algorithm for UTIs

Uncomplicated Cystitis in Women

1. First-line options:

   • Nitrofurantoin 100 mg twice daily for 5 days
   • Fosfomycin trometamol 3 g single dose
   • Pivmecillinam 400 mg three times daily for 3-5 days 1

2. Alternative options (when first-line agents cannot be used):

   • Cephalosporins (e.g., cefadroxil 500 mg twice daily for 3 days)
   • Trimethoprim 200 mg twice daily for 5 days (not in first trimester of pregnancy)
   • Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days (not in last trimester of pregnancy) 1

UTIs in Men

• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7 days
• Fluoroquinolones can be prescribed according to local susceptibility testing 1

Acute Pyelonephritis

1. Oral treatment (mild to moderate cases):

   • Ciprofloxacin 500-750 mg twice daily for 7 days
   • Levofloxacin 750 mg once daily for 5 days
   • Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 14 days 1

2. Parenteral treatment (severe cases):

   • Ciprofloxacin 400 mg twice daily
   • Ceftriaxone 1-2 g daily
   • Cefotaxime 2 g three times daily 1

Special Considerations

Pregnant Women

• First-line treatments include nitrofurantoin, cephalosporins (particularly cephalexin), or fosfomycin
• Recommended doses:
  • Nitrofurantoin 100 mg four times daily for 5-7 days
  • Cephalexin 500 mg four times daily for 7 days
  • Fosfomycin as a single dose 2
• Treatment duration should be at least 7 days (except for fosfomycin)
• Test-of-cure urine culture should be obtained 1-2 weeks after treatment 2

Recurrent UTIs

Recurrent UTIs are defined as ≥3 UTIs per year or ≥2 UTIs in 6 months 1

1. Non-antimicrobial prevention strategies:

   • For postmenopausal women: Vaginal estrogen replacement (strong recommendation) 1
   • Immunoactive prophylaxis (strong recommendation) 1
   • Increased fluid intake for premenopausal women (weak recommendation) 1
   • Methenamine hippurate for women without urinary tract abnormalities (strong recommendation) 1

2. Antimicrobial prophylaxis (when non-antimicrobial interventions fail):

   • Continuous or post-coital antimicrobial prophylaxis 1
   • For good compliance patients, self-administered short-term therapy 1

Treatment Failures

• If symptoms don't resolve by the end of treatment or recur within 2 weeks:
  • Obtain urine culture and antimicrobial susceptibility testing
  • Assume the infecting organism is not susceptible to the original agent
  • Retreat with a 7-day regimen using another antimicrobial agent 1

Common Pitfalls to Avoid

1. Treating asymptomatic bacteriuria - This can foster antimicrobial resistance and increase recurrent UTI episodes 1

2. Using fluoroquinolones as first-line therapy - These should be reserved for more invasive infections due to increasing resistance and risk of adverse effects 1, 3

3. Failing to consider local resistance patterns - Local antibiograms should guide empiric therapy, especially for trimethoprim-sulfamethoxazole (should only be used when local resistance is <20%) 3, 4

4. Inadequate treatment duration - Single-dose therapy (except for fosfomycin) is not recommended due to lower cure rates 2

5. Classifying patients with recurrent UTIs as "complicated" - This often leads to unnecessary use of broad-spectrum antibiotics with longer treatment durations 1

By following this evidence-based approach to UTI treatment, clinicians can effectively manage infections while practicing antimicrobial stewardship and minimizing the risk of treatment failure and recurrence.